Patient Safety Friends

08/19/2011

We organize and express our thoughts with words, verbal labels. As parameters of thought, those labels are both helpful and limiting.

At the repository of medical articles maintained by the National Library of Medicine, PubMed ( http://www.ncbi.nlm.nih.gov/pubmed), the medical literature is indexed using "Medical Subject Headings," sometimes referred to as "MeSH" headings or "mesh" terms. You can search for MeSH labels here http://www.ncbi.nlm.nih.gov/mesh. One of the ways to search for articles is to search for articles to which particular labels have been attached. If you find an article addressing a subject of interest, you can click on "related citations" to find similar articles.

Sadly, there is no MeSH label for "patient safety." By way of contrast, there are MeSH subject headings for:

The label "patient safety" is not used to index the medical literature. It is not a concept recognized by the National Library of Medicine. Our concepts govern how we think and how we organize information. The concepts determine the information we can find, or, as is true for so many, the information we cannot find perhaps because we don't think it exists.

According to the MeSH subject headings, "patient safety" is not a concept.

This is not an idle concern about indexing or the appropriate concepts labels that are used. The indexing structure used makes it easier, or more difficult, to find the information needed. Clearly, the goal of an indexing system should be to make finding literature easier. The MeSH labeling system fails to meet that goal.

It is so bad that even leading experts in the field who are preparing review articles have to devote enormous time and energy to locating relevant information. Karimi et. al (2010) explain the problem in the article's abstract:

The process of constructing a systematic review, a document that compiles the published evidence pertaining to a specified medical topic, is intensely time-consuming, often taking a team of researchers over a year,with the identification of relevant published research comprising a substantial portion of the effort. The standard paradigm for this information-seeking task is to use Boolean search; however, this leaves the user(s) the requirement of examining every returned result. Further, our experience is that effective Boolean queries for this specific task are extremely difficult to formulate and typically require multiple iterations of refinement before being finalized.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2966450/pdf/1472-6947-10-58.pdf. If the experts who are asked to prepare review articles encounter so much difficulty, one can only guess how clinicians treating patients fare in their literature searches. The time devoted to such searches is an enormous waste of time that could be spent researching, writing, or treating patients. Making literature difficult to find does not benefit patients.

It seems strange that in our digital era, we continue organizing information in such a clumsy manner that it takes months before even experts can find the information they need. The sad irony is that people cannot find the information then need simply because the indexing system fails. The information is, as a practical matter, unavailable to them.

The current indexing system needs to be replaced with something that works.

11/29/2010

The British Medical Journal reported today on a debate over the benefits of malpractice litigation at the Risky Business conference in London earlier this month. Glasgow University Professor Shelia McLean argued that litigation creates secrecy and defensiveness, and preventes the open discussion necessary to learn from mistakes. Available to only a few who can afford lawyers, litigation precludes the collaboration necessary to prevent future mistakes. (See http://www.bmj.com/content/341/bmj.c6703 or http://www.ncbi.nlm.nih.gov/sites/pubmed/21106631.) Barrister James Badenoch contended that fear of litigation was the “principal driver of risk management and risk avoidance.” The cost of the proposed alternative no fault system is prohibitive.

Does Debate Miss the Point?

Whether these two positions are inconsistent seems to depend on whether litigation alone is supposed to eliminate bad medical care. Probably, both Badenoch and McLean would agree that litigation system provides an incentive to eliminate poor care. Probably, both would agree that:

litigation has not yet accomplished that goal, and

litigation alone is insufficient to solve the problem.

This apparent disagreement over whether "litigation is a good method for dealing with medical malpractice" masks the real issue:

We should not lightly toss aside a Constitutional right without a compelling reason. Those who want us to abandon our Sixth Amendment rights ought to show, at a minimum, that the benefits outweigh the cost. Where is the benefit to sacrificing this right? There is no basis for believing that sacrificing a constitutional right is likely to make patient care safer. In fact, the opposite is true. The most successful safety effort began with closed claims.

Litigation was the first essential component of the most effective patient safety effort to date: the anesthesia closed claims project. That project began by examining closed medical malpractice claims. It devised strategies for preventing the harm to the patients. Without litigation, the most effective patient safety effort to date would not exist. There would be no starting point.

Eliminating litigation would seem unwise for at least three reasons.

The failure of litigation alone to solve the malpractice problem does not mean that litigation is not a part of a solution.

The only successful attempt to solve the malpractice problem has been based on data from litigation.

Eliminating litigation infringes on a constitutional right.

Medical Malpractice System: Provides Incentive and Starting Point

Medical malpractice litigation serves two purposes: it provides an incentive to fix the medical system, and the data that serves as the starting point for making repairs. Alone, medical malpractice litigation cannot fix problems in the healthcare system that the healthcare system does not want to acknowledge or fix.

11/28/2010

No Progress

Sadly, yet another study shows that many patients are harmed by their medical care, iatrogenic injury. Worse, significant effort over the past decade by leading minds in medicine, state and federal governments, professional medical associations and thousands of advocates have produced little impact. The most recent study indicates that the rate of patient harm produced by medical error remains relatively constant. (See http://www.nejm.org/doi/full/10.1056/NEJMsa1004404#t=article. The abstract appears at http://www.ncbi.nlm.nih.gov/pubmed/21105794.)

The Study: Respected Researchers Review 588 Cases

Despite some criticism of the methodology, the study cannot be lightly dismissed. The authors reviewed 588 cases randomly selected from 10 hospitals in North Carolina, a state generally respected in the medical community for its attempts to promote safe patient care. The authors are well published and respected. A search of Pubmed identifies over 350 articles by these authors dating back to 1973 (http://tinyurl.com/356-articles-by-Landrigan-etc) 39 of which are review articles (http://tinyurl.com/39-reviews-by-Landrigan-etc). (Note: they have published 11 articles in both JAMA and the New England Journal of Medicine. ) Landrigan and his co-authors hold prominent positions in medicine.

Several events from the last year have changed how we think about patient safety. We are beginning to appreciate the central role of nurses in our health care system. How do we think about the role of nurses?

Our language underscores our recognition of the central role of nurses in the healthcare system. Consider how we talk about vulnerable or sick patients. When we are sickest, we are "nursed" back to health. The highest level of care is one-on-one "nursing" care. Fragile newborns are cared for in the "nursery." Elderly can receive care in "nursing" homes, not "doctoring" homes or "hospital" homes. Despite the critical role of nurses, events of the last year suggest that nurses remain unappreciated.

February witnessed the Texas criminal trial arising out of two nurses, Anne Mitchell and Vicki Galle, having reported atrocious "medical" practices to the Texas Board of Medicine. http://tinyurl.com/NY-Times-on-Texas-Nurses This outrageous prosecution should have led to everyone who claims to support patient safety to stand up for these nurses. Curiously, the only professional societies who stood with these two Texas nurses were nursing societies. Despite the fact that the past AMA president was from Texas, the organization was curiously silent. Likewise, I could find no statements of support from any professional societies of physicians or hospital administrators. The deafening silence of the rest of organized medicine, except for the nurses' organizations, raises questions about whether the talk about patient safety is simply lip service. (Note: Please feel free to use the "comment" section below to share any support that Anne Mitchell and Vicki Galle received from physician or hospital organizations.)

A simmering dispute between the Temple University Hospital administration and nurses' union came to a boil in March and April.http://tinyurl.com/Temple-Gag-Order-on-Nurses-Un One of the central issues in the dispute was the administration's insistence on a "gag clause." As Mary Ellen Mannix explains:

In Minnesota and California, nurses have begun taking stands on high patient to nurse ratios that threaten patient safety. According to Med City News, the president and CEO of Minnesota's HealthPartners, Mary Brainerd, rejects the demand of the nurses for staffing ratios. The union for the nurses is seeking to establish staffing levels that are safe for patients. Minnesota Nurse's Association. California nurses point to recent studies showing that staffing levels are associated with lower rates of patient deaths.

The loudest voices for safe nurse-to-patient ratios comes from the ranks of the nurses. Their message:nurses are willing to strike for safer staffing levels. These are the same voices that inspired the phrases we use to describe the places and methods of care for the weak and the ill: "nursing homes," "newborn nurseries," and "nursing back to health."

When physicians and hospital administrators in Kermit, Texas, looked the other way on the dubious practices of Dr. Rolando Arafiles, it was two brave nurses who faced criminal prosecution for standing up. In Philadelphia, Minneapolis and California, the nurses are the ones willing to risk their jobs and strike for safer care.

Earlier this year, this blog asked all of us to "stand up for the Texas nurses. " http://tinyurl.com/stand-with-the-texas-nurses To quote another Texan, this request may have "misunderestimated" the importance of nurses. As this year has progressed, we have seen that nurses are the ones willing to risk what they have for our safety. These are the same nurses who enjoy less pay and prestige than physicians and hospital administrators. The nurses regularly staff the evening and midnight shifts, make sure we receive our medications, and clean up our bodily fluids. Was it the devotion of the nurses to our well being that attracted them to this profession? Was their experience of seeing how their care made a difference in our health what empowered them to risk their jobs for our safety? The answers to these questions can and will be disputed.

More important are the answers to some other questions. When it came time to expose Dr. Rolando Arafiles' misconduct, where were the physicians and hospital administrators? When it came time to protect the right of the Temple nurses to speak out against unsafe practices, where were the advocates for speaking out for patient safety? Even after studies show that ratios of nurses to patients affect the rate of patient death, only the nurses seem willing to take a stand for better ratios. Much remains to be accomplished on the patient safety front.

Nevertheless, one conclusion remains indisputable: it is the nurses who have been standing up for us all along.

02/24/2010

A February 26, 2006, Cleveland, Ohio, pharmacist's error in mixing medication for two year old Emily Jerry took her life. Criminal prosecution of the pharmacist has generated detailed newspaper reports. 12 34 56

For too long, most errors have been ignored by the medical profession and the media. The deaths of children unrelated to celebrities are usually not considered "newsworthy." I have not been able to find any news stories about Emily Jerry's death published in 2006, the year she died. The earliest article I have found is a January 2007 article about "Emily's Law" being enacted. The error was subsequently discussed in newspaper articles covering some aspect of the legal proceedings: the criminal charges against the pharmacist, the licensure hearings against the pharmacist, the pharmacist's being released from jail, or the push for state regulation of pharmacy technicians. Without those events,

I would never have been aware of this case. I fear that the public discussion of this case would not have occurred. Sadly, the only vehicle most families have to advance public discussion of medical mishaps are legal proceedings.

Stories about particular medical errors rarely appear in the press. Notable exceptions include incidents involving Congressman John Murtha and Dennis Quaid's children. Rep. Murtha developed a complication following a routine surgery. The news reports on the surgical complication leading to his death have covered it in detail. 789 Dennis Quaid has devoted enormous energy to exposing a massive overdose of heparin given to his twins. While such stories about medical errors affecting families of celebrities are rare, the media coverage has directed scrutiny to the underlying problems. Hospital drug errors far from uncommon. Actor Tells 60 Minutes' Steve Kroft Medical Errors Kill ThousandsThese public discussions are quite valuable.

Patient safety leaders Dr. Robert Wachter (Link: X) and Dr. Michael Cohen (Link: Y) criticize the criminal prosecution of Emily Jerry's pharmacist for a human mistake. They reason that nothing is accomplished by prosecuting an individual for a simple human error. They argue that the criminal proceedings fail to address the underlying "systems issues" that created the error. They conclude that the criminal proceedings fail to solve the problems and may be counterproductive by discouraging reporting of errors.

To evaluate their positions, let us make make a few distinctions. First, let us distinguish two goals: a. being fair to the pharmacist and b. making patient care safer. Just for the sake of argument, let's assume that Wachter and Cohen are correct that this prosecution failed to achieve the first goal, that it was unfair to the pharmacist. While being fair to pharmacists matters, so does the loss of Emily Jerry's life and that of other children. Preventing avoidable patient deaths will prevent criminal prosecutions for manslaughter and negligent homicide. Safe patient care would completely prevent criminal prosecutions for negligent homicide or manslaughter.

Imagine that the pharmacist had been sentenced to a longer prison term, for instance a ten or twenty year sentence, or life in prison. There would have been an outcry had the pharmacist been sentenced to death. Pharmacists, health care providers of every kind, and activists would organize fundraising activities to hire the best appellate lawyers, letter writing campaigns, teach-ins at universities, and perhaps even lobbying for a pardon from a governor or the president. Amnesty International might designate the pharmacist as one of individuals whose case it champions. The effort would be enormous. I would likely contribute time and money to prevent the execution of someone guilty of making garden variety human mistake. Such mistakes do not justify the death penalty.

If the death penalty cannot be justified for so-called ordinary mistakes, then it cannot be justified for simply being an innocent child. Emily Jerry's life was at least as important as the pharmacist's. Preventing the death of the next Emily Jerry is worth at least that much effort: organizing fundraising activities, hiring staff, letter writing campaigns, teach-ins at universities, lobbying the governor or president. We can try persuading Amnesty International and other organizations to give priority to preventing the deaths of the next, the next ten, the next hundred, the next million patients like Emily Jerry.

Emily Jerry's life is at least as important as the pharmacist's life

Unlike this pharmacist, Emily Jerry did not get out of jail after six months. Emily Jerry will not get out of jail in five, ten or even twenty years. Emily Jerry will not even have the chance to spend the rest of her life in jail. Emily Jerry, well, Emily Jerry got a death penalty. It was an accident, but she is just as dead.

Most cannot even imagine the anguish. If someone kidnapped or jailed our child for the six months the pharmacist spent in jail, we would be enraged. Suppose our child had been kept for five or ten or twenty years. We read the news stories about a young woman recently reunited with her family after being abducted decades ago. The trauma to Emily Jerry's family is greater. The trauma to families whose loved ones die from medical errors is just as great. Where is the outrage and the demand for change?

Suppose we offered this deal to Kelly Jerry: in exchange for her daughter's life, she spends six months in jail. At the end of the six months, she is re-united with her daughter. If the family had the opportunity to prevent their daughter's death by subjecting themselves to the same penalty endured by the pharmacist, they would be overjoyed.

Those who focus on the plight of the pharmacist completely miss the point. We need to re design medicine so that this NEVER happens again. Small incremental changes are not enough. There have been millions of these errors even though one is too many. Some safety activists wonder why we don't get the point. If the number of patients that are killed by medical errors were killed by plane crashes, the outcry would be overwhelming.

I do not suggest more punishment for this or any other pharmacist. We can eliminate the criminal prosecutions of pharmacists by preventing the dispensing errors that kill people. Preventing these errors is a moral imperative. We just do not get it. A beautiful little girl dies and our outrage is directed towards the prosecution of a pharmacist who spends six months in jail. Anyone would choose the pharmacist's fate over Emily Jerry's.

Everyone in patient safety knows that Emily Jerry will not be the last two year old child to die of a medication error. There will be at least another ten, another hundred, and another thousand dead children. Are we willing to stop it?

Medication errors such as this one occur daily in America. People die. Had prior occurrences of this error been publicized, perhaps the problem with medication errors would have been solved. Perhaps publicizing such an error in 1994, or 1997, or even one in 2001 could have prevented Emily's tragic death. Imagine that the medication error of February 26 had been avoided. Emily Jerry would be alive. The pharmacist would not have been prosecuted.

I found no articles in the press about Emily Jerry's death in March and April 2006. (If I missed one, please let me know. )

Why wasn't Emily Jerry's death, in and of itself, sufficient to spark outrage over and publicity for the medical error that killed her? Our acceptance of such medical errors that kill beautiful two year old children and the fact that these events are almost never reported in the media has allowed the errors to multiply.

We must end the silence. We must express outrage over the death of this child. The moral imperative is to stop these mistakes. If the legal system is the only way to generate attention for these errors, we must use it. Lives are at stake.

Unsafe medical care cannot thrive without secrecy. We will not have safe care so long as we allow silence to shield bad medical practice from public view. The continuing silence of
organized medicine about the criminal prosecution of two Winkler County Memorial County nurses case dashes my hopes that the problem can self-correct.

Two nurses in Kermit, Texas, tried to end the silence about the unsafe medical care at Winkler County Memorial Hospital. The nurses anonymously reported a physician to the Texas Board of Medicine. After receiving a notice from the Board, the physician enlisted the assistance of the sheriff, and an investigation was launched. Search warrants located copies of the formerly anonymous correspondence with the Board on the computers of nurses Vicki Galle and Anne Mitchell. As a result, the nurses lost their jobs, their careers, and were charged with ten year felonies. Anne Mitchell and Vicki Galle have faced those felony charges since last June. Shortly before trial, the case against Vicki Galle was dropped and Anne Mitchell was pronounced "Not Guilty" by a jury. 1 2345678

After the "Not Guilty" verdict (see earlier posts), the American
Federation of Teachers issued a statement supporting the nurses. (Statement. Also see here.) Other
than the nursing associations and a rather unusual statement from the
AAPS, organized medicine has been silent. (The statement by the AAPS was hardly supportive of the nurses. While I acknowledge the statement insisting on accountability of those who criticize doctors, it does not seem to qualify as support. There was no support that I could discern in its press release.)

Silence is the enemy of patient safety. All the
powers that be in Kermit, Texas, tried to silence these brave
nurses. Nursing organizations from all over the country objected. As of the writing of this post, only the teachers union has joined the nursing organizations in objecting. The message that the rest of us will stand by silently while attempts are made to silence nurses reverberates. One can only wonder how many nurses nationwide felt the
message of intimidation. http://tinyurl.com/patient-safety-intimidation Will other nurses follow the example of Mitchell and Galle? Other than the teachers, they cannot find any reason to believe that anyone other than other nurses will support them. Will these other nurses be willing to give up their jobs and careers? Will they now have to consider what they will do if they have to go to jail for ten years? Doesn't the silence of the rest of organized medicine (other than the nurses) discourage future whistleblowers?

When it mattered, when nurses reporting unsafe
medical care were attacked by the local authorities for refusing
to be silent, where was organized medicine's support? What was the message sent?
Silence.

Was organized medicine trying to show all of its critics,
by example, how Anne Mitchell and Vicki Galle should have behaved? Was organized medicine telling everyone who blows the whistle what kind
of support to expect when they blow the whistle? Wasn't the lack of support for these nurses the problem: Silence. Silence in response to poor patient care. Silence in response to an absurd prosecution. Silence in response to criticism. Silence and more silence.

Silence Is The Problem

It is not too late. With the trial over, the stakes
are lower. With the trial over, taking a position on this prosecution
will not take any courage or guts. With the trial over, the facts have
been decided and investigation is no longer necessary. We know that when it mattered, when it could have
helped the brave nurses, organized medicine was completely silent (with
the notable exception of nursing associations). I applaud the Texas Nurses Association, the American Nurses Association, and the many other nursing associations that have supported the nurses when it mattered. Where is everyone else?

Now
that it matters less, is organized medicine still silent? How is it
that the American Federation of Teachers was able to take a position supporting the nurses, but organized medicine has not? Where are the doctors and hospitals? Where are the professional medical organizations other than the nurses?

Are the nurses and teachers alone in their support of the nurses? Let us hear from you. If I have missed any organizations supporting Anne Mitchell and Vicki Galle, correct my mistake here. Add the name of the organization and the link.

May, June 2009 - Sheriff Roberts seeks to identify the author(s) of the anonymous complaint. (See page 29 HERE.) Search warrants (See pages 32 - 34 HERE.) lead to his finding a copy of the anonymous complaint on the computers of Mitchell and Galle. The two nurses are fired and indicted for ten year felonies. (See pages 37 and 38 HERE.)The Texas Board of Medicine is unsuccessful in educating the local authorities about the laws protecting those who file reports of poor medical care with the board of medicine. (See pages 39 to 42 HERE.) The prosecution goes forward.

July, August, September, October 2009 - This case is discussed in several national healthcare publications including Modern Healthcare (See PubmedEncyclopedia), RN, and the American Journal of Nursing (here,here and here). Medical news listservs carry stories about the case (Medical News Today,. Nursing groups issue statements and establish legal defense fund supporting nurses Galle and Mitchell. Other than nursing associations (see link), organized medicine is silent. The prosecution goes forward.

November, December 2009 - A state inspection of Winkler County Memorial Hospital corroborates the complaint filed by the nurses earlier in the year. Organized medicine remains silent. The prosecution goes forward.

January, February 2009 - With the exception of one association organized medicine remains silent.Just before trial is to begin, charges against Nurse Galle are dropped. Trial begins on February 8. On February 10 the American Association of Physicians and Surgeons issues press release in support of holding accountable those who criticize physicians. (Press Release) The four day trial results in a verdict of "Not Guilty." Out less than an hour, the jury reaches its unanimous verdict on the first vote.

After the trial, the American Federation of Teachers issues a statement supporting the nurses.

Silence:

The Goal, The Tactic, The Method

While we instinctively celebrate this jury's correct "Not Guilty" verdict, a disturbing message has been sent to everyone in America who cares about safe healthcare. The message is not the one from from Kermit, Texas. It came from Chicago and Washington, DC. It came from Los Angeles and Boston, New York and St. Louis, Cincinnati and Seattle, Phoenix and Miami. It came from hospital associations and doctors. It came from everywhere and nowhere. The message was silence.

Silence was the goal and the method. The bullies wanted to silence the nurses. The bullies wanted to teach a lesson to those who stood up for patients: be silent. This message was not the most troubling. We have come to expect unusual politics in small towns. Is it really so bad that this outrageous prosecution occurred in a tiny hamlet in west Texas? What can the rest of America really know about the private goings on in small towns in west Texas? We really do not know what happened. Can't the Texas court system straighten this out in the unlikely event that the nurses are convicted? Does this really matter so much?

With the exception of the strong support of the nursing community, the nurses were alone.

The truly disturbing response came from almost every corner of America. Empty silence. Loud silence. Intentional silence. Important silence. It seemed as if the rest of organized medicine was showing the nurses and everyone else how to behave when you observe something wrong: be silent.

In this case, the bullies hid behind badges and law licenses. They used search warrants and indictments. Despite their law degrees and badges, they pretended the law did not exist even after being informed by the Texas Board of Medicine. The bullies ignored 45 CFR 164.512(d),and Texas law 217.19, 301.4025, 242.133, 160.012, and 554.002. They assaulted the truth. They damaged the public health. Yet organized medicine remained silent.

Can we trust silence? When patient safety is at stake, we cannot.

Is patient safety compromised by silent nurses?

Patient safety was compromised by the silence of organized medicine in response to this prosecution. Can we trust those who are silent in response to obvious injustice?

Texas Jury returns verdict of "Not Guilty" in criminal prosecution of Texas Nurses. I have spoken with one of the lawyers involved with the defense. Let's make sure Anne Mitchell and Vicki Galle know we support them. Add your name to this list:

During this comedy of errors, Anne Mitchell and Vicki Galle have made us proud. When faced with difficult choices, they chose to do the right thing. They were aware that if discovered, they could lose their jobs. They still chose the morally correct course of action. That choice exacted a toll. They lost their jobs, and were prosecuted by bullies hiding behind badges. Ms. Mitchell and Galle sacrificed their careers and suffered criminal prosecution. They put their professional obligations to protect their patients first. They put the community interest and health ahead of their jobs.

What happened to them was wrong. Both suffered. They lost their jobs, endured pressure and public humiliation, and faced the prospect of losing their freedom. They lost much of their privacy after newspapers and professional journals discussed their case.

Their courage changed the world. Healthcare everywhere in America will be at least a little safer because of them. Whether employed in the healthcare arena or not, all have been inspired by Anne Mitchell and Vicki Galle. When we find ourselves making difficult decisions, we can comfort ourselves by remembering them. We can discuss these events with our children as they make choices and ask them to do "what Anne and Vicki would have done."

Law schools, medical schools, nursing schools and other professional training courses have a new topic to teach. Conferences and seminars will discuss this case. Education has a new subject. Anne Mitchell and Vicki Galle made all this possible by forging this path.

We cannot change the past. We can tell Anne Mitchell and Vicki Galle:

"We are grateful for your courage, your common sense, and your values. We applaud you and celebrate your example. We are proud to stand with you."

02/10/2010

As a malpractice lawyer, I hear the claim that my medical malpractice claims are frivolous. My perspective is skewed. Once I represented the family of a child who spent three of his first four hours of life in the morgue. The child is alive today. It was the most egregious malpractice case I have ever seen. While flying back to the office from the first deposition in the case, the defense attorney suggested that I would do better to focus my energies on one of my "meritorious cases." His comment convinced me that his judgment was impaired. I decided to ignore anything he would say in the future.

I used to say that a "frivolous case" was one in which you were the defendant. Anyone can describe any meritorious as frivolous. It isn't hard.

The criminal prosecution of Anne Mitchell and her former co-defendant Vicki Galle, my two new heroes, is the most absurd filing I have seen in my career. Whether the scope of its absurdity can be reduced to a list of reasons is unclear. It puts the public health at risk. It betrays the mission of the courts, law enforcement, and several state institutions. All of the professionals on the prosecution side of this case have betrayed common sense, the public health, the public interest and their professional obligations.

Even a cursory review of the statutes and regulations cited in the Federal Complaint filed by the nurses shows that the actions of the nurses is legally protected. I probably will never visit Kermit, Texas. Apparently, the law means nothing there.

45 CFR 164.512(d).

Texas Administrative Code 217.19

Section 301.4025

Section 242.133

Section 160.012

Section 554.00

Finally the national media is beginning to notice this absurd abuse of our legal system.

"As nurses, the first duty is to the patient, caring for them and when necessary, protecting them. While doctors take an oath to "first do no harm" sometimes it is nurses who prevent them from doing harm. I've seen it more times than I care to think about in my own practice.

"So what kind of nurse do you want? The one who is watching out for you, or the one who is afraid to watch out for you?

"Shame on the town of Kermit, Texas for their failure to censure an out of control sheriff and for their failure to support the nurses who cared for them.

"Shame on doctor Rolando G. Arafiles Jr!

"Shame on Sheriff Robert L Roberts!

"Shame on Winkler County Memorial Hospital in Texas for firing nurses who care about patients... and keeping doctors who shouldn't.

"BRAVO to Vickilyn Galle and Anne Mitchell. May there always be nurses like you to protect patients from incompetent physicians, especially those who are friends with the sheriff. You are my nursing heroes."